Factors that influence uptake of routine postnatal care: Findings on women’s perspectives from a qualitative evidence synthesis

Background Effective postnatal care is important for optimal care of women and newborns–to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care. Methods We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach. Findings Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women’s desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care. Conclusions Factors that influence women’s utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings. Registration This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.


Methods
We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach. Findings Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women's desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care.

Conclusions
Factors that influence women's utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings.

Registration
This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.

Background
Postnatal care (PNC) is a fundamental component of the maternal, newborn and child care continuum, and contributes to reducing maternal and neonatal morbidity and mortality and improving overall health and wellbeing [1][2][3]. It is generally defined as the care provided during the postnatal period, beginning immediately after childbirth and up to six weeks (42 days) after birth [1] or beyond [4]. PNC represents a set of healthcare services designed to promote the health of women and newborns; it includes risk identification, preventive measures, health education and promotion, and management or referral for complications. Postnatal care not only improves mortality and clinical care, but also affects the satisfaction and experience of health care users; understanding the experiences and needs of women and their families with regard to postnatal care can improve utilization and positive experiences. The World Health Organisation (WHO) recommends that all women and newborns receive postnatal care in the first 24 hours following childbirth, regardless of where the birth occurs, and subsequent postnatal check-ups in the first six weeks [5]. Nevertheless, postnatal care ranks among the lowest coverage of maternal and child health services interventions; after facility discharge, only 31% of women and 13% of newborns receive a postnatal check [6,7]. Previous studies have also identified important socioeconomic and geographic inequities in access to and utilisation of postnatal care services [8].
Over the last two decades, there have been multiple contributions to a large and growing canon of literature on facilitators and barriers to maternity care, including recent systematic reviews [9][10][11]. However, most of these studies have focused on care-seeking for intrapartum care and immediate PNC (within 24 hours), and not later (e.g. post discharge) postnatal care [12][13][14]. Much of the literature on maternity care focuses on facilitators and barriers to utilization [15][16][17][18] but, as low quality care has recently been associated with a potentially higher attributable risk of mortality than lack of access [19], studies have begun to examine perceived and actual quality of care, including disrespect and abuse at facilities, as contributing factors to low utilisation of maternal health services [15][16][17][18]. Very few studies have examined the impact of mistreatment or disrespect of newborns as discouraging factors for uptake of postnatal care, but recent studies have demonstrated the importance of satisfaction with maternal and neonatal care on subsequent care utilization [20,21]. This paper presents the results of a sub-set of the data from a qualitative evidence synthesis designed to explore the views and experiences of women, their partners, families and communities in the postnatal period, and factors that influence uptake of routine postnatal care. For this analysis, our aim was to assess the views and experiences of women in the general population in accessing routine postnatal care for themselves and their infants.

Methods
We included qualitative or mixed-methods studies where the focus was the views of women in the general population (i.e. excluding sub-populations such as adolescents or migrants) on factors that influence uptake of routine postnatal care (i.e. those without additional postnatal needs due to comorbidities or identified medical risk), irrespective of parity, mode of delivery, or place of delivery. Qualitative studies and mixed methods studies were those that included a qualitative component, either for design (i.e. ethnography, phenomenology), data collection (i.e. focus groups, interviews, observations, diaries, oral histories), or analysis (i.e. thematic analysis, framework approach, grounded theory).
A framework approach was used to inductively develop initial themes [22] and thematic synthesis [23] and was then used iteratively based on the initial thematic framework. Study assessment included the use of a validated quality appraisal tool [24]. Confidence in the findings was assessed using the GRADE-CERQual tool [25].

Definitions
We define the postnatal period as the time between birth, including the immediate postpartum period (first 24 hours after birth), and up to six weeks (42 days) after birth [1]. This period varies cross-culturally, but usually coincides with confinement periods and other cultural practices in the 30-45 days following birth.
We define 'routine postnatal care' as formal service provision that is specifically designed to support, advise, inform, educate, identify those at risk and, where necessary, manage or refer women or newborns, to ensure optimal transition from childbirth to motherhood and childhood. Postnatal care can include a wide range of activities, including risk identification (assessments, screening), prevention of complications, health education and promotion (infant feeding and care, life-skills education, postpartum family planning, nutrition, vaccines, mental health support, and prevention and management of harmful practices-including smoking and alcohol-and violence) and support for families. Routine postnatal care does not typically include specialist services for comorbidities, address social needs, or the management of conditions not related to pregnancy or postpartum care, though referrals can be made for such services as a result of routine postnatal care.

Reflexive statement
Our study team included a medical doctor, a midwife, epidemiologists, public health researchers, and librarians, all with extensive experience in the provision and study of maternal and neonatal healthcare. We began this study with anecdotal and experiential knowledge that postnatal care is very often unavailable or inadequate, with minimal emphasis on the psychosocial needs. We believed PNC to be poorly and inequitably accessible, even in high-income settings, and especially in low-and middle-income countries (LMICs), and that due to perceived or actual poor quality care, including potential fears of mistreatment, and services not being userfriendly, families may be discouraged from seeking care. Multiple members of our study team have been involved in the direct provision of postnatal care, and in developing national and international guidelines for postnatal care.

Search strategy
The search strategy was developed with senior librarians based on the following concepts: barriers and limitations, postnatal care, and health services needs and demands. The search was limited to qualitative and mixed-methods studies (see S1 Appendix). Databases searched included MEDLINE (OVID), PubMed, CINAHL (EBSCO), EMBASE (OVID), and EBM-Reviews (OVID), as well as a search for grey literature. The search strategy covered papers published from inception through December 2019. There were no language restrictions. Hand searching was used to identify grey literature documents on the following websites: BASE (Bielefeld University Library), OpenGrey, and on the World Health Organization. Duplicates were excluded through the EndNote X9 software using a method developed by Bramer et al. [26] Inclusion and exclusion criteria are presented in Table 1.

Study selection
We collated records into Covidence software, excluded duplicates, and screened records based on title and abstract. To check for consistency, two members of the study team independently screened the titles and abstracts against the a priori inclusion/exclusion criteria and excluded irrelevant records. Before assessment of the full-texts of papers, records were categorised as follows: 1. Either "general population" or sub-populations such as adolescents, migrants 2. "Women's view's only", "partners and family views only", or "women's, and partner/family views".
3. Either high-income (HIC) or low or middle-income (LMIC) country setting, using the 2019 World Bank Classification Scheme.
In accord with the global nature of the review, and to ensure sufficient representation of country levels especially lower income settings, we divided the studies into either HIC or LMIC for sampling. Due to the very large number of eligible papers, 40 papers (~15%) from each geographic group (HIC or LMIC) were randomly sampled at a time, and screening and extraction was conducted until it was agreed by consensus that thematic saturation was reached for each geographic group, at which point 10 additional papers were selected from each group for confirmatory analysis (if saturation was not, 20 more papers were selected for that group, until it was agreed that saturation was reached, at which point a confirmatory set was then selected). Prior to undertaking this process, it was agreed that, if no further themes were identified after confirmatory analysis, the group was considered saturated.
Extraction of data and assessment of quality was conducted for each eligible paper by study team members. Disagreements were settled by consensus among reviewers. Themes from HIC and LMIC groups were analysed together, which notations made where the specifics or manifestation of each theme different between country groups.
Study team members did not assess papers in which they were a co-author. Two of the included studies were published in a language other than English: a Brazilian study [27] was analysed by one of the study team members fluent in Portuguese and a Japanese study [28] was translated by a Japanese-speaker into English prior to analysis. All quotes included in this manuscript were translated into English by the study authors, the respective study team members, or colleagues who assisted with translation.
Papers which did not meet either the general or specific inclusion criteria upon full review were either excluded or put aside to be evaluated separately for future analysis. Studies which did not include first-hand reports of women's experiences were excluded; studies which focused exclusively on a sub-population (e.g. young adolescent mothers) were put aside for separate subsequent analysis.

Data extraction and analysis
Data extraction, analysis and quality appraisal proceeded concurrently and broadly followed the 'best fit' framework approach described by Carroll [22]. Based on previous related reviews of antenatal care [29] and intrapartum care [30] as well as a recent thematic synthesis of 'what matters to women' during the postnatal period [31] we used a deductive approach to develop a thematic framework comprising four broad concepts (Resources and access; Behaviours and attitudes; External influences; What women want and need) as well as a number of sub-themes (see S2 Appendix). We then used thematic synthesis techniques [23] to confirm our a priori framework, or to develop new themes where emerging data failed to fit. We began by using an Excel spreadsheet to record pertinent details from each study (e.g. author, country, publication date, study design, setting and location of birth, setting and location of postnatal care, sample size, data collection methods, participant demographics, contexts, study objectives). The four concepts from our a priori framework were added to the Excel sheet and the author-identified findings from each study were extracted (along with supporting quotes) and mapped to the framework as appropriate. Any codes which did not map to the framework were placed in a section marked 'other' to allow for the emergence of new sub-themes or concepts. This process included looking for what was similar between papers and for what contradicted ('disconfirms') the emerging themes. For the disconfirming process we consciously looked for data that would contradict our emerging themes, or our prior beliefs, and views related to the topic of the review.

Quality assessment
Included studies were appraised using an instrument developed by Walsh and Downe [32] and modified by Downe et al. [33]. Studies were rated against 11 pre-defined criteria [33], and then allocated a score from A-D (including + and -), where A+ was the highest and Dthe lowest (see Table 2). Studies rated with a D were excluded from further data analysis. Studies were appraised by each reviewer independently and a 10% sample was crosschecked by a different study team member to ensure consistency. Each reviewer was asked to extract and assess both LMIC and HIC papers in order to increase intra-rater reliability between the two geographic groups. Any studies where there were scoring discrepancies of more than a grade were referred to another study team member for moderation.
Once the framework of descriptive themes (or review findings) was agreed by the study team, the level of confidence in each review finding was assessed using the GRADE-CERQual tool [34] and agreed by consensus between two study team members. GRADE-CERQual assesses the methodological limitations and relevance to the review of the studies contributing to a review finding, the coherence of the review finding, and the adequacy of data supporting a review finding. Based on these criteria, review findings were graded for confidence using a Table 2. Ratings for quality assessments of studies.
• A represented a study with no, or few flaws, with high credibility, transferability, dependability and confirmability.
• B, a study with some flaws, unlikely to affect the credibility, transferability, dependability and/or confirmability of the study.
• C, a study with some flaws that may affect the credibility, transferability, dependability and/or confirmability of the study.
• D, a study with significant flaws that are very likely to affect the credibility, transferability, dependability and/or confirmability of the study.
https://doi.org/10.1371/journal.pone.0270264.t002 classification system ranging from 'high' to 'moderate' to 'low' to 'very low'. Following CERQual assessment the review findings were grouped into higher order analytical themes and the final framework was agreed by consensus amongst the study team.

Papers included in overall study and analytic sample
Our systematic searches yielded 12,678 records, of which 17 were duplicates. An additional 12,149 were excluded by title and by abstract, leaving 602 for full text review (See Fig 1). Our final list of articles for the analytic sample included 59 studies with views from women in the general population on routine postnatal care, with 32 coming from HICs and 27 from LMICs. Specifically, of the LMIC studies, 6 were from low income countries, 12 from lowermiddle income countries, and 9 from upper-middle income countries. The global representation of studies was reasonably wide with 17 coming from Europe, 13 from Africa, 10 from North America, 9 from Asia, 4 from the Middle East, 4 from Australasia, and 2 from South America. The two South American studies were both from Brazil and, although we actively searched our entire database for studies from other Latin American countries, no others fulfilled our inclusion criteria. The studies were generally of good quality with an average quality rating of B and were mainly qualitative and descriptive in design. A full list of the included studies with relevant characteristics is shown in Table 3.

Findings
This process generated 20 review findings. Following discussions amongst the study team, these descriptive themes were then mapped against our a priori framework themes to generate our final analytical themes. Resources and Access was split into two separate themes: Access and Availability and Physical and Human Resources. We changed Behaviours and Attitudes to Social Norms to better reflect the larger group of stakeholders influencing maternal choice or behaviour, and we changed the title of What Women Want and Need to Experience of Care to better reflect the experiential nature of the findings.
Our analysis reinforced some aspects of the themes in our a priori framework and modified or expanded others. This final framework includes twenty-one themes and five overarching study findings: Access and Availability; Physical and Human Resources; External Influences; Social Norms; and Experience of Care. Our final framework displaying the analytical themes and descriptive themes, with their associated CERQual gradings, is shown in Table 4.

Themes identified from included studies
Access and availability. Whilst proximity to a health facility appeared to encourage engagement with maternity providers, our evidence suggests that, for some women living in remote or rural areas, a lack of transport or the poor quality of transport networks limited attendance at postnatal clinics. This was compounded in situations where women did not have the personal resources to pay for relatively expensive journeys to health facilities and/or could not afford to take time away from their work or family. Even in high income settings where access to postnatal services is ostensibly free at point of care, the additional costs associated with attendance including insurance levies, childcare costs, and transport costs limited engagement for women living in poverty.
For accessing postnatal care post-discharge from a health facility after birth, women wanted a wide range of possible options and flexible schedules for reaching healthcare workers. Women generally valued the ability to contact providers at convenient times even more so than having a large number of contacts. Women wanted to be able to get support during moments of high stress, or on their schedules, rather than on a pre-defined health systems schedule, and many referenced the value of their time. Women expressed frustration about not being able to reach healthcare workers when needed. Service providers that were able to      offer more flexible opportunities for engagement like drop-in clinics, telephone contacts, out of hours services and, in particular, home visits, were viewed more positively. Physical and human resources. For women in a variety of different settings, the ability to engage with formal postnatal services was influenced by resource and infrastructure constraints, especially in settings where community-based services were limited or non-existent. The evidence also suggests that the poor availability of resources in some health facilities may act as a deterrent to women who might otherwise benefit from postnatal care. A lack of basic medicine and equipment and inadequate or inconsistent water or electricity supplies limited attendance in some low-income settings. Whilst the availability of essential equipment and utilities was not reported to be an issue in most high-income countries, women were sometimes aware of staff shortages on postnatal wards and this affected their experience of care. Women's perception that some health facilities were understaffed, especially from studies in LMICs, was also reflected in the length of time they had to wait to be seen by a healthcare provider. In some instances, this was compounded by cursory and impersonal exchanges with care providers, leaving women feeling frustrated, annoyed and undervalued.
External influences. Women identified several external influences as having a bearing on their engagement with postnatal services. These ranged from environmental influences such as the physical condition of the health facility itself to the availability and affordability of private providers to a willingness (or otherwise) to engage with traditional postnatal practices, either in accordance with or against the advice of family and community members.
For women in a variety of different settings and contexts, the condition of postnatal wards and health facilities was important. Women used words such as 'clean' and 'modern' to frame positive perceptions or 'dirty' and 'unhygienic' to highlight negative experiences. These negative accounts were more commonly associated with facilities in low-income settings but even in high income countries women used words like 'dilapidated' and 'unwelcoming' to describe postnatal wards. In addition to the condition of the buildings, women also commented on the

Personal resources:
In the included studies, additional costs associated with transport to and from health facilities, payment for childcare, healthcare insurance payments, the potential costs of medicines for mother or newborn as well as the loss of household income associated with clinic attendance all acted as barriers to PNC engagement. Low "Those who go for weight monitoring spend less time at the clinic than those who go for vaccination. This is because there is one health care provider; we suggest that there is a need to increase the number of health care providers" [Mrisho 2009, Tanzania] (Continued ) and disruptive atmosphere on the postnatal ward generated feelings of frustration and despair, prompting a few to leave earlier than planned.
For women who gave birth at home, the relatively calm and familiar home environment enabled them to feel more relaxed and in control of their immediate postnatal experiences. "PNC is just for the child. There is nothing for the mother. All other services that follow soon after birth are for the child." [Mrisho 2009, Tanzania].
Low 15. Gender of healthcare providers-In studies from some LMIC settings, women felt their needs and sensitivities during the postnatal period were better understood by female health providers and were sometimes ashamed or embarrassed to be seen by a male healthcare provider. In one specific context women felt unsafe if they received a home visit from a male healthcare provider.   High "Having no sleep, having no rest and thinking maybe the hospital staff will give the mother a rest by taking the baby away, for a couple of hours would be amazing, but there's none of that, there was no help, and I actually asked for the help. . . I think it was the second night I just broke down in tears, because I was so exhausted, in so much agony. . . And I asked for help and they said look, we don't do that. I was a bit surprised that, that help wasn't available. [Puthussery 2010, UK].
17. Psychosocial support-For many women in the included studies, predominantly in HIC settings, the postnatal period elicited a range of extreme emotions from great joy to exasperation and despair. To cope with these feelings women often received support from family and friends and welcomed frequent reassurance from healthcare providers. Some women expressed a need to discuss their birth with a healthcare provider (ideally someone who was present at the birth) and sometimes they highlighted a need to discuss their anxieties, their fear of responsibility or their perceived insecurities about living up to the ideal of a 'good mother'. "When I leave, I feel really good, and every time we leave she says "You're doing a great job, mom. Keep it up" And that just makes me feel so good leaving the office. . .. that you have a doctor who's really paying attention to you and your daughter, or your child, and then just confirms for you when you leave, like "Keep it up. You're doing awesome. She's healthy, she's happy". So that is a huge deal" [Aston 2018, Canada].
High "I would appreciate if it was part of the routine to have a little talk after the birth. . .it doesn't need to be a long talk or so. . .just as long as you get to meet the midwife who was there". [Persson 2011, Sweden]. "And I think there is a preconceived image of the ideal mother. When I asked friends who gave birth at the same time as me: 'how is your daughter? Is she crying a lot?' They all told me no. They said no, she never cries. Recently, I asked them again about it, and they then said that they could not even take a shower! And I said to them: 'but I thought that she did not cry?' And even worse, they had not told me the truth, and I found this extremely distressing. I do not know, it is all a facade" [Razurel 2011, Switzerland].
18. Information needs-For many women in the included studies, largely in HIC contexts, the birth of a newborn triggered a huge array of informational needs. Some of these needs were met by friends, family, peers or the internet but women looked to healthcare providers for specific information about their infant's feeding, crying or sleeping behaviours as well as clinical information relating to safety, development and overall wellbeing. Women also looked to providers for information about their own needs relating to wound care, the resumption of sex, contraception and their general wellbeing. For some women the amount of information provided was too little or given at the 'wrong' time (antenatally or immediately after birth) whilst for others the volume of information given by providers was excessive, inappropriate or inconsistent.

Acknowledgement of women-Women in studies from
predominantly HIC settings expressed a desire to be 'seen' by healthcare providers. Most women understood and appreciated the focus of care on their infant's wellbeing and suppressed or ignored their own need for attention. They were sometimes surprised and relieved when sensitive healthcare staff enquired about their wellbeing but, more often than not, felt disappointed, unsupported and uncared for when their need for attention or simply to be acknowledged was ignored or overlooked. "That someone came to your home to ask you how YOU were doing was something I appreciated. Everyone tended to ask about the baby, but suddenly there was someone who wanted to know how WE were doing after the birth". [Dahlberg 2016, Norway].
High "It's kind of disheartening when they come in and ask for (baby) first, because I'm hurting too" [Gaboury, 2017 Canada].

Continuity of carer-Women
in studies from a variety of different HIC settings and contexts highlighted the importance of forming a trusting relationship with a healthcare provider. For some women this entailed seeing the same provider for all aspects of maternity care (from antenatal to postnatal), for others it was important to receive postnatal care from a provider who was present at the birth, and, for a few, simply seeing the same person at each postnatal contact was a key component of quality care. For women who chose to have homebirths the prospect of seeing the same midwife throughout their maternity journey was an important factor in their decision-making.  lack of physical space in some facilities and how this impacted on their sense of personal space and perception of privacy. Some women felt the opportunity to engage in confidential conversations with family members or healthcare providers was compromised whilst others felt the shared facilities and tight surroundings in some postnatal wards generated a noisy and disruptive atmosphere. For mothers who already felt exhausted and fatigued from childbirth, the impact of this environment coupled with their inability to control system-oriented, organizational routines, led to feelings of frustration and exasperation. By contrast, for women who gave birth at home, the nurturing nature of familiar surroundings as well as their ability to establish personal routines and control access to their home created a more relaxing environment. In settings where private facilities were available, they were generally considered to be of better quality and were utilised by some women with the financial means to do so. However, in some contexts, the integration between private and public providers was inadequate and impacted on women's engagement with postnatal services once they were discharged from the health facility.
Women's capacity to engage with postnatal services was influenced by other family members and individuals in their social circles. In some contexts, women's autonomy was inhibited by patriarchal social structures and decisions relating to engagement with maternity services, including postnatal care, were largely deferred to husbands. Sometimes, these kinds of decisions were agreed jointly between the woman's husband and her mother-in-law and sometimes the decision was solely the responsibility of the mother-in-law.
Women expressed that elderly relatives and the broader beliefs and expectations of local communities influenced their observance of traditional postnatal practices rather than 'westernised' approaches to postnatal care, which some may have preferred. In some rural communities, especially in Africa, the reliance on TBAs to administer specific herbs and medicines in the postnatal period was integral to a communal belief system, whilst in other settings it was simply more convenient or financially viable. For other women, especially in Asia, the cultural practice of 'doing the month' involved extended periods of isolation and seclusion and limited interaction with formal postnatal services. Our findings also indicate that, in these contexts, some women (and their families) found it difficult to steer a course between the increasing influence of "Western" approaches to postnatal care and adhering to the traditional practices advocated by previous generations.
Social norms. Women highlighted a variety of behaviours and understandings about the health system that affected their willingness to engage with postnatal care providers. For some women, especially from studies in LMICs, these understandings were based on a perception that attendance at health facilities offering postnatal care was only necessary if they felt unwell or if there was a problem with their infant. In many cases, this notion was reinforced by healthcare providers who did not encourage attendance or devalued the services they offered. When health workers devalued PNC, families also tended to devalue PNC and not see the need to seek care.
Some women also believed that postnatal services were solely focused on infant wellbeing and development and, although they valued the services on offer for newborns (clinical assessments and immunizations), they were not aware of, or did not acknowledge, any sources of care and support for themselves.
For some women, a reluctance to engage with postnatal services was rooted in a lack of trust in the system. In certain contexts, this was based on a perception that some providers were corrupt and expected informal payments, gifts, or bribes in return for care. In other settings, women's trust in the system was undermined by perceived inadequacies in the clinical or personal skills of the healthcare providers. More infrequently, women complained that confidential information shared with health providers might be compromised or abused and, in more extreme cases, women believed that disclosure of mental health issues (like postnatal depression) might lead to their infant being taken away from them. In a few specific contexts, women expressed a preference to be seen by female health providers and highlighted safety concerns when postnatal visits at home were conducted by male health workers.
Experience of care. Based on their experiences of postnatal care, women identified a range of issues that were of particular importance during their postnatal journey, including the need for information and support and the desire to be treated with care and respect by familiar and trusted healthcare providers.
Women from a variety of different settings and contexts highlighted the need for information during all phases of postnatal care. Although some of these informational needs were met by friends, peers, family members and online sources, women looked to healthcare providers for information about infant nutrition and development as well as tips and advice on infant crying cues, sleeping patterns, breastfeeding, and safety concerns. Although women tended to prioritise the needs of their newborns over their own, they also sought personal information for example on wound care, contraception, and when to resume sexual activity. The timing and delivery of information was also discussed by many women indicating that information should be supplied both antenatally and postnatally and given in a clear and consistent format. For some women, intense emotions of joy and elation coupled with feelings of extreme fatigue affected their ability to absorb information in the immediate postnatal period, whilst for others, the sheer volume of information was difficult to process.
In addition to a need for information, women also identified needs for both practical support and, especially in high-income countries, for psychosocial support. In a practical sense, women appreciated the support they received from family members but also valued support from healthcare providers, particularly in the immediate postpartum period, prior to hospital discharge, when they were trying to bond with their newborn and/or establish breastfeeding. Help with specific newborn-oriented tasks like nappy changing and bathing as well as tending to the newborn whilst the mothers recuperated, showered, or carried out chores, were highlighted and, in some instances, women felt disappointed when these needs were not recognised.
In many settings, women also highlighted the need for ongoing practical support once they returned home and, although this was often facilitated by family members, women also appreciated assistance from healthcare providers during the transition to motherhood. Usually this was a continuation of the advice received in hospital relating to infant feeding and development but, in uncommon circumstances, women received visits from associated agency workers to helped with domestic activities (shopping, cleaning, cooking) and these services were highly valued.
Many women experienced intense emotional peaks and troughs during the postpartum period ranging from elation to despair to overwhelming exhaustion. Women, particularly first-time mothers, discussed their fears, anxieties, and insecurities about becoming a mother and, for some, the pressure and responsibility of living up to some idealised version of a mother. Women wanted support from healthcare providers to help them to process and manage these difficult emotions and often expressed this in terms of a need for reassurance. In some contexts, particularly in high-income settings, where much of the published evidence comes from, women wanted to discuss the birth experience with a midwife who was present or have access to healthcare providers support if they felt their birth was challenging or traumatic.
In a broader sense, many women felt that their own care needs were overlooked or undervalued during the postpartum period. Whilst new mothers completely accepted and understood that the focus of postnatal care was on their infant, they nevertheless felt disappointed when unvoiced pleas for attention or recognition were ignored by healthcare providers.
Our findings also indicate that women placed great importance on their ability to build a relationship with care providers and this was particularly apparent in high-income settings. For some women this involved seeing the same healthcare provider at each postnatal contact, for others it meant being able to see the same midwife during the postnatal period as they saw antenatally, and for women who gave birth at home, the prospect of having the same midwife throughout their maternity journey played a significant role in their decision to opt for a homebirth. Where women were able to build these relationships, they were more likely to report 'a sense of companionship', 'trust' and 'authenticity', but in settings where continuity of healthcare models were not in place, women reported feeling 'dissatisfied', 'like a number' or even, 'like an animal'.
For women in several contexts, interactions with healthcare providers sometimes became disrespectful and abusive. In high income settings, women indicated that healthcare providers could be rude or undermining and occasionally discriminatory during postnatal encounters, whilst in lower-income contexts women reported acts of rudeness, humiliation and, in rare cases, punishment by health providers.

Discussion
Factors that influence women's utilization of postnatal care are interlinked, and include access, quality, and social norms. Five review findings were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care.
Staffing and resources were important to women, although in low-resource settings, more emphasis was placed on poor physical infrastructure. In low-and middle-income countries, women further expressed that healthcare providers themselves often devalued postnatal care, contributing to their lack of utilization and sense of unpreparedness. Many studies from highincome countries highlighted women's desire for more psychosocial and emotional support; yet, women in low income settings may not have been asked as directly about this challenge. Women also may not believe this is a role of the health system, or may not feel comfortable stating this as a vulnerability. These findings point to the need to strengthen comprehensive health care services, which can more fully address the holistic and ongoing needs of women and their families.
Many of the findings related to experience of care derived from high-income countries. Because of the number of included studies related to this topic were biased toward high income countries, this review finding should not be interpreted necessarily as women in lowand middle-income countries having positive experiences of care; evidence indicates that disrespectful practices are common globally [93]. This area is understudied in low-and middleincome countries and therefore it is difficult to draw robust conclusions. However, it is likely that women in settings with insufficient resources will more often refer to unhygienic conditions or lack of equipment as a more immediate priority than their experiences, and/or that they perceive less ability to change the situation than women in settings with more resources. A recent qualitative evidence review of studies in sub-Saharan Africa affirmed that aspects of respectful and disrespectful maternity care and women's previous experiences of health care influenced their "decisions to access postnatal care services" [94]. The fact that many of the studies related to experience of care are from high-income settings may reflect the study authors' biases and points to the need to study women and families' experiences more holistically in low-and middle-income settings.
When situating this review within the context of other research [29], many similarities emerge in review findings across various phases of maternity care. From antenatal and intrapartum through postnatal care, women emphasised the need for information, continuity of care, adequate resources, and comprehensive and holistic support. Access and cost continue to be issues for many women, especially in low-and middle-income countries and in rural areas, but compared with intrapartum care, the incentive to overcome these challenges is further diminished with the devaluing of postnatal care and perception of low need for healthy women and their healthy infants. In the postnatal period, women's access needs include when and how they can contact healthcare providers and for what purposes. Women greatly value continuity of care and flexible schedules for obtaining information and assistance. Infrastructure and health system resources play into both decisions about if and when to seek care, as well as the experience of care itself. This pattern and commonality across maternity care periods reflects the fact women may seek care from the same places and thus experience some of the same facilitators and challenges, but also emphasises women's perception that maternity and the postnatal period are a continuum. The factors influencing postnatal care utilization may be different than other maternal and child health services for a number of reasons: postnatal may not be seen as important (especially if the woman and newborn are apparently healthy); during the postnatal care period, maternal and newborn needs may arise at the same time, adding to complexity of recognition and care seeking; and health care visits may take place in the home, unlike visits which must take place in a health facility. However, many of the same factors may be at play, including the recognition of need, the perception of quality, and the physical barriers such as cost and distance.
The review findings on postnatal care utilization largely conform with previous studies around what women want during this time period, as well as challenges related to access, health system quality, and experience of care. Our review builds on previous work in postnatal care utilization by explicitly including both women and newborns. The strengths of this review include a rigorous methodology, comprehensive search, very large database, wide search terms and concepts, and a diverse study team. Our review encompassed a geographically and linguistically diverse search, with a balance of papers from high, middle, and low-income countries, although the number of available studies from certain regions (e.g. Latin America and the Eastern Mediterranean) were limited. Despite the design of the search to be global, including a lack of language restrictions, we identified few papers from Australasia, Middle East, and South America.
Some potential limitations of the study include the limitations of the included papers themselves, especially the different prioritised topics studied in different regions of the world. Although the objectives of the included papers represented a range of topics, it is possible that certain areas, as well as certain topics in each region, are understudied. While we acknowledge that there may be context specific issues, we are bound by the content of the included studies and recognise that different questions may have been posed to participants in different contexts, depending on the nature of the research inquiry and the pre-existing beliefs of the research team members of those particular studies. Further, the World Bank Country Classifications are broad and group countries with very different profiles together. Country-specific terminology (such as the specific words used in a particular setting around health insurance or a certain cadre of support worker) may not have been captured.
As with other systematic reviews, there is a trade-off between speed and comprehensiveness and, while our use of sampling could limit our interpretation, our iterative process until reaching saturation increases confidence in our findings [95,96]. New studies have been published since the end of the search that were not included, however, the comprehensiveness and rigor of our search and analysis provides confidence in the findings.
Many papers identified in our search included the term "postnatal care" but in fact referred only to intrapartum care. It was difficult to disentangle experiences of postnatal care by time period as this was rarely disaggregated in studies. The differentiation was included in our extraction form, but some papers reported on when data were collected and others on the period the respondents were referring to with the latter often encompassing multiple time points post birth. More research is needed in distinguishing the needs during the immediate (e.g. pre-discharge from a health facility) and later postnatal periods.
The findings from this study have implications at the individual, family, health system, and policy levels, and interventions may be needed to address factors at each. Individual empowerment of women may be insufficient if her partner, family, or community have significant influence in healthcare decisions. The desire of women to have increased emotional and psychosocial support may or may not be best served by existing cadres of medical providers. Future research should explore who the optimal providers might be and what the scope (and burden) might be for each type of provider, including traditional birth attendants [97] and non-medical carers. The intervening time from the end of our search to completion of analysis included the emergence of a global pandemic, which has already had significant impact on postnatal experiences and care utilization [98,99]. Further areas of research include the impact of the pandemic on care utilization, increased anxiety and psychosocial support needs [100], and the role of digital and virtual care technologies [101].
There are clear steps which can be taken to improve the quality, experience, and uptake of care for women and newborns in the postnatal period. The value of PNC should be promoted as part of quality improvement, health worker training, and community mobilization. As much as possible, care should be provided in a continuous and coordinated manner, between health facilities, clinics, medical offices, communities, and households. At each level there must be sufficient staffing, resources, and infrastructure to provide high quality of care. Efforts should be taken to eliminate barriers to cost and transport, including illegal or unethical barriers such as bribes and other out-of-pocket or unanticipated costs for care, and all types of abuse and denial of care.

Conclusions
Postnatal care must be positioned as a high priority for both the woman and the newborn, much like antenatal and intrapartum care, and not seen as an optional service, or one only accessed in cases of emergencies. As a pre-requisite for increased utilization of postnatal care, quality must be improved [102]. The benefit of postnatal care for the mother and entire family may increase utilization, especially if services are available to improve emotional and psychosocial support. The implementation of standards for quality of care and respectful care must move beyond childbirth to ensure a positive experience of postnatal care for all women and their newborns.